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Файл:Ординатура / Хирургия / Библиотека им академика М.И. Перельмана / Книга_2669_Библиотеки_им_академика_М_И_Перельмана
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Mitral Regurgitation - Intervention
– Transcatheter edge-to-edge repair: Severe secondary MR LVEF <50% with NYHA II-
IV symptoms on maximum GDMT with LVEF 20-50%, LVESD ≦ 70 mm and PA
systolic pressure ≦ 70 mmHg
– Surgical repair: Severe secondary MR at the time of CABG
– Surgery:
• Severe secondary MR with LVEF ≥50% and NYHA III-IV symptoms despite GDMT
• Severe secondary MR with LVEF <50% with NYHA III-IV symptoms despite GDMT
• May consider surgical replacement over repair (annulus dilation from LV
remodeling/dilation may make the repair very challenging)
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BONUS
Read on own
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Tricuspid Regurgitation
TR can be primary or secondary as well
• Primary
: lead-related, trauma, IE, rheumatic, carcinoid, CTDz, …
• Secondary
: Pulm HTN-related, RV-related, RA-related
Severe TR is defined using specific echocardiographic parameters that you should not need to know
Class I indications for surgery:
• Severe TR in patients undergoing left sided valve surgery
Class IIa indications for surgery:
• Addition of an annuloplasty ring for moderate or more TR at the time of left sided valve surgery
• Severe primary or secondary TR if right sided heart failure and no pulmonary hypertension to reduce symptoms and risk
of heart failure hospitalization
*NEW* TRILUMINATE trial (NEJM, 2023): in patients with severe tricuspid with NYHA II-IV symptoms, without pulmonary
hypertension, on maximized medical therapy (diuretics), transcatheter edge to edge repair (TriClip) was associated with
reduced TR and symptoms compared with medical therapy alone, but no differences in mortality or heart failure
hospitalization
• These devices are not yet guideline recommended but are an active area of research and recommendations may come
in future years.
AHA 2014, 2017, 2020 Valve
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Antithrombotic Therapy After
Valve Replacement
Mechanical Valves *** NO DOACs ***
• Lifelong therapy with warfarin; add ASA if other antiplatelet indication
• Goal INR varies with: type of valve, valve position, patient risk factors
– *NEW* INR 1.5-2.0 ON-X valve (useful if INR monitoring/compliance issues, needs low dose ASA)
– INR 2.5 (2-3)for current generation AVR and no other risk factors
– INR 3.0 (2.5-3.5) for any MVR or old AVR (ball-in-cage) or AVR with risk factors (RF = AF, prior clot, LV dysfxn,
hypercoagulable state)
– Bridging for invasive procedures is reasonable when the INR is subtherapeutic based on an individualized
assessment of thrombosis and bleeding (see perioperative medicine lecture)
Bioprosthetic Valves
• Lifelong therapy with ASA 75-100mg daily
• Initial 3-6 months post-implantation
– Surgical valve replacement à consider VKA (INR 2.5) in addition to ASA
– TAVI à may consider DAPT (clopidogrel) or VKA (INR 2.5) if low risk bleed (ASA monotherapy likely safer per guideline text)
• Bioprosthetic valve (within 3 months) + new onset AF à VKA
AHA 2020 Valve
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Infective Endocarditis
• Will be covered in another section (Infectious Disease)
• Know:
– Class I Indications for surgery
– Indications for prophylaxis against infective endocarditis
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Category Private Car Commercial Driver (Truck, Bus)
Valvular
Heart
Disease
Medically treated
AS, AI, MS, MR, TR
AS: OK if NYHA 1-2
MS, MR, AI, TR: OK if NYHA 1-3
Only OK if in the lowest risk group: NYHA 1, no
syncope, LVEF ≧ 50%
AS, AI: as above
MR: also no pHTN or systemic embolism (?error)
MS: no LVEF requirement
TR: no RV dysfunction, symptomatic RV failure, RV
arrhythmias
Post TAVI or SAVR for AS, AR 1 month if stable QRS duration, no
high grade AV block (2
nd
type II or
3
rd
) if no PPM and NYHA I-III
AR requires as above + LVE F ≧ 50%
3 month if stable QRS duration, no high grade AV
block (2
nd
type II or 3rd) if no PPM and NYHA I
AR requires as above + LVE F ≧ 50%
Post TEER for MR or TR 48h post d/c if NYHA I-III 1 month post d/c if NYHA I and LVEF ≧ 50%
Post balloon valvuloplasty for MS 48h post d/c if NYHA I-III 1 month post d/c if NYHA I
Post TMVR, TTVR or surgical valve
replacement
1 month post d/c if NYHA I-III 3 months post d/c if NYHA I and LVEF ≧ 50%
CCS 2023 Fitness to Drive Guidelines - Valves
New recommendations for TAVI, TEER, TMVR, TTVRSyncope restriction removed from private driving
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MCQ #2 2024
A 79 year old woman with a history of hypertension is re-evaluated in clinic regarding 3 months of
exertional dyspnea. She has NYHA II-III symptoms. She has no orthopnea, PND or peripheral edema. She
has no angina. Her exam is significant for a 3/6 mid to late peaking systolic murmur best heard at the right
upper sternal border. Her ECG shows normal sinus rhythm with LVH and associated repolarization changes.
Pulmonary function testing and chest imaging are within normal limits. Her NT-pro BNP is mildly elevated
at 1000. A coronary angiogram performed last month did not show any obstructive coronary artery disease.
A transthoracic echocardiogram commented on hyperdynamic systolic function, with an LVEF of 65%,
severe LVH and a small LV cavity. The aortic valve is calcified, though the mean gradients are only mildly
elevated at 25 mmHg. The interpreting cardiologist notes possible paroxysmal low-flow-low-gradient aortic
stenosis, as the stroke volume index is low at 25 mL/m2 (reference cut off 35 mL/m2). What is your next
test of choice to better evaluate her aortic valve severity?
A. Exercise stress echocardiogram
B. Dobutamine stress echocardiogram
C. Persantine myocardial perfusion scan
D. Cardiac CT aortic valve calcium score
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Answer: D. This stem describes paradoxical low-flow-low-gradient AS.
The next step Cardiac CT for calcium scoring of the valve (>2000 in
men, >1200 in women indicates severe). Exercise stress echo and
Persantine myocardial perfusion for ischemia are unlikely to be helpful
given recent normal coronary angiogram. Dobutamine stress echo
would be the test of choice for classic LFLG AS (with reduced LVEF)
and would not be helpful here with a patient with preserved LV
function.
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Aortopathy
Key Resources:
• ACC/AHA 2022 Aortic Disease Guidelines
• CCS 2014 TAD Guidelines
• CCS 2023 The Aortic Team Model and Collaborative Decision
Pathways for the Management of Complex Aortic Disease
(online November 9, 2023)
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MCQ #3 2024
A 45 year old man with a history of hypertension and tobacco use undergoes a
transthoracic echocardiogram for a murmur heard incidentally on routine physical
examination. This demonstrates an ascending aorta aneurysm of 4.6 cm, with a
trileaflet aortic valve with mild-moderate aortic regurgitation. Of the following
recommendations, which would not be appropriate at this time?
A. Refer to an Aortic Team for further evaluation and surveillance.
B. Obtain a CT angiogram or MRI to characterize of the thoracic aorta.
C. Obtain a full family history and refer for genetic testing. Genetic testing and/or
screening imaging of family members will need to be performed.
D. Start him on a calcium channel blocker to manage his blood pressure if greater
than 130/80mmHg.
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• Often presents as a “tearing” or
“ripping” pain radiating to the back.
• Can present as several “mimics”:
– ACS (e.g. STEMI) – usually inferior STEMI
– Valvular heart disease (aortic regurgitation
leading to heart failure)
– Pericardial effusion, cardiac tamponade
– Syncope
– Stroke, focal neuro symptoms
– Renal failure, limb ischemia, spinal cord
injury
• Risk factors include hypertension,
vasculitis, valvular heart disease (esp.
Bicuspid AV), drugs (cocaine), collagen
disorders (Marfan, Ehlers-Danlos)
• Look for
– focal neuro deficit (LR+ 6.6-33)
– Pulse deficit/differential BP (LR+ 5.7)
!!! CHECK BILATERAL BPs !!!
– Enlarged aorta or mediastinum on CXR (LR+
2.0)
• CT scan is best first-line imaging modality
– Others à MR, TEE
CCS 2014 Thoracic Aortic Disease; JAMA RCE
Thoracic Aortic Dissection
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Thoracic Aortic Dissection
• Management
– Preferentially use IV meds (easy on / easy off), in ICU setting with arterial line monitoring
– BBs first line (or CCBs if BB contraindication/intolerance) à vasodilators (nitroprusside, ACEI)
– Control HR
• Ta rget H R < 60-80
• IV labetalol good 1
st
line option (both HR and BP)
– Control BP
• DO NOT control BP before HR (
hypotension à compensatory incr. HR à more shear stress
)
• Target BP <120 systolic (or to lowest BP that maintains adequate perfusion)
– Control pain with as needed analgesics (will help with hemodynamics)
– Further management depends on type of dissection (Stanford Classification – Type A or B)
• Type A à dissection involves ascending aorta à refer for urgent surgical intervention
• Type B
à
dissection does not involve ascending aorta à medical management à HR and BP
control
– Exception: if the type B dissection causes malperfusion (e.g. gut ischemia, leg ischemia), endovascular
management will be necessary. Rupture is another rare indication for surgery
ACC/AHA 2022 Aortic Disease
CCS 2014 Thoracic Aortic Disease
CCS 2023 Complex Aortic Disease
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